|
INSERT FX BEAR STB SZ 4 10MM
|
Facility
|
OP
|
$15,862.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,758.78 |
| Max. Negotiated Rate |
$15,228.10 |
| Rate for Payer: Aetna Commercial |
$12,214.20
|
| Rate for Payer: Anthem Medicaid |
$5,455.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,372.83
|
| Rate for Payer: Cash Price |
$7,931.30
|
| Rate for Payer: Cigna Commercial |
$13,165.96
|
| Rate for Payer: First Health Commercial |
$15,069.47
|
| Rate for Payer: Humana Commercial |
$13,483.21
|
| Rate for Payer: Humana KY Medicaid |
$5,455.15
|
| Rate for Payer: Kentucky WC Medicaid |
$5,510.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,007.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,706.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,758.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,564.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,959.09
|
| Rate for Payer: Ohio Health Group HMO |
$11,896.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,690.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,800.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,945.19
|
| Rate for Payer: PHCS Commercial |
$15,228.10
|
| Rate for Payer: United Healthcare All Payer |
$13,959.09
|
|
|
INSERT GEN II PS FLEX SZ 1-2
|
Facility
|
IP
|
$5,090.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,527.00 |
| Max. Negotiated Rate |
$4,886.40 |
| Rate for Payer: Aetna Commercial |
$3,919.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,970.20
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cigna Commercial |
$4,224.70
|
| Rate for Payer: First Health Commercial |
$4,835.50
|
| Rate for Payer: Humana Commercial |
$4,326.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,173.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,756.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,527.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,479.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,817.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,428.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.10
|
| Rate for Payer: PHCS Commercial |
$4,886.40
|
| Rate for Payer: United Healthcare All Payer |
$4,479.20
|
|
|
INSERT GEN II PS FLEX SZ 1-2
|
Facility
|
OP
|
$5,090.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,527.00 |
| Max. Negotiated Rate |
$4,886.40 |
| Rate for Payer: Aetna Commercial |
$3,919.30
|
| Rate for Payer: Anthem Medicaid |
$1,750.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,970.20
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cigna Commercial |
$4,224.70
|
| Rate for Payer: First Health Commercial |
$4,835.50
|
| Rate for Payer: Humana Commercial |
$4,326.50
|
| Rate for Payer: Humana KY Medicaid |
$1,750.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,768.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,173.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,756.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,527.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,785.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,479.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,817.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,428.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.10
|
| Rate for Payer: PHCS Commercial |
$4,886.40
|
| Rate for Payer: United Healthcare All Payer |
$4,479.20
|
|
|
INSERT GEN II PS FLEX SZ 5-6
|
Facility
|
OP
|
$5,090.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,527.00 |
| Max. Negotiated Rate |
$4,886.40 |
| Rate for Payer: Aetna Commercial |
$3,919.30
|
| Rate for Payer: Anthem Medicaid |
$1,750.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,970.20
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cigna Commercial |
$4,224.70
|
| Rate for Payer: First Health Commercial |
$4,835.50
|
| Rate for Payer: Humana Commercial |
$4,326.50
|
| Rate for Payer: Humana KY Medicaid |
$1,750.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,768.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,173.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,756.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,527.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,785.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,479.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,817.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,428.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.10
|
| Rate for Payer: PHCS Commercial |
$4,886.40
|
| Rate for Payer: United Healthcare All Payer |
$4,479.20
|
|
|
INSERT GEN II PS FLEX SZ 5-6
|
Facility
|
IP
|
$5,090.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,527.00 |
| Max. Negotiated Rate |
$4,886.40 |
| Rate for Payer: Aetna Commercial |
$3,919.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,970.20
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cigna Commercial |
$4,224.70
|
| Rate for Payer: First Health Commercial |
$4,835.50
|
| Rate for Payer: Humana Commercial |
$4,326.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,173.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,756.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,527.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,479.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,817.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,428.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.10
|
| Rate for Payer: PHCS Commercial |
$4,886.40
|
| Rate for Payer: United Healthcare All Payer |
$4,479.20
|
|
|
INSERT GII PS SZ 3-4 11MM
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT GII PS SZ 3-4 11MM
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT GII PS SZ 3-4 9MM
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT GII PS SZ 3-4 9MM
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT GII PS SZ 5-6 11MM
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT GII PS SZ 5-6 11MM
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT GII PS SZ 5-6 9MM
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT GII PS SZ 5-6 9MM
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT IABP PERCUTANEOUS
|
Facility
|
IP
|
$3,553.00
|
|
|
Service Code
|
HCPCS 33967
|
| Hospital Charge Code |
48100003
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,065.90 |
| Max. Negotiated Rate |
$3,410.88 |
| Rate for Payer: Aetna Commercial |
$2,735.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,771.34
|
| Rate for Payer: Cash Price |
$1,776.50
|
| Rate for Payer: Cigna Commercial |
$2,948.99
|
| Rate for Payer: First Health Commercial |
$3,375.35
|
| Rate for Payer: Humana Commercial |
$3,020.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,913.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,622.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,065.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,126.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,664.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,842.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,091.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,451.57
|
| Rate for Payer: PHCS Commercial |
$3,410.88
|
| Rate for Payer: United Healthcare All Payer |
$3,126.64
|
|
|
INSERT IABP PERCUTANEOUS
|
Professional
|
Both
|
$3,720.10
|
|
|
Service Code
|
HCPCS 33967
|
| Hospital Charge Code |
76101324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$198.21 |
| Max. Negotiated Rate |
$2,232.06 |
| Rate for Payer: Aetna Commercial |
$462.26
|
| Rate for Payer: Ambetter Exchange |
$241.93
|
| Rate for Payer: Anthem Medicaid |
$198.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$241.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$241.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$290.32
|
| Rate for Payer: Cash Price |
$1,860.05
|
| Rate for Payer: Cash Price |
$1,860.05
|
| Rate for Payer: Cigna Commercial |
$420.59
|
| Rate for Payer: Healthspan PPO |
$454.50
|
| Rate for Payer: Humana Medicaid |
$198.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$377.15
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$241.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$241.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$202.17
|
| Rate for Payer: Molina Healthcare Passport |
$198.21
|
| Rate for Payer: Multiplan PHCS |
$2,232.06
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$314.51
|
| Rate for Payer: UHCCP Medicaid |
$1,302.04
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$200.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$241.93
|
|
|
INSERT IABP PERCUTANEOUS
|
Facility
|
OP
|
$3,553.00
|
|
|
Service Code
|
HCPCS 33967
|
| Hospital Charge Code |
48100003
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,065.90 |
| Max. Negotiated Rate |
$3,410.88 |
| Rate for Payer: Aetna Commercial |
$2,735.81
|
| Rate for Payer: Anthem Medicaid |
$1,221.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,771.34
|
| Rate for Payer: Cash Price |
$1,776.50
|
| Rate for Payer: Cigna Commercial |
$2,948.99
|
| Rate for Payer: First Health Commercial |
$3,375.35
|
| Rate for Payer: Humana Commercial |
$3,020.05
|
| Rate for Payer: Humana KY Medicaid |
$1,221.88
|
| Rate for Payer: Kentucky WC Medicaid |
$1,234.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,913.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,622.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,065.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,246.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,126.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,664.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,842.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,091.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,451.57
|
| Rate for Payer: PHCS Commercial |
$3,410.88
|
| Rate for Payer: United Healthcare All Payer |
$3,126.64
|
|
|
INSERT IABP PERCUTANEOUS
|
Facility
|
IP
|
$3,720.10
|
|
|
Service Code
|
HCPCS 33967
|
| Hospital Charge Code |
76101324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,116.03 |
| Max. Negotiated Rate |
$3,571.30 |
| Rate for Payer: Aetna Commercial |
$2,864.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,901.68
|
| Rate for Payer: Cash Price |
$1,860.05
|
| Rate for Payer: Cigna Commercial |
$3,087.68
|
| Rate for Payer: First Health Commercial |
$3,534.09
|
| Rate for Payer: Humana Commercial |
$3,162.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,050.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,745.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,116.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,273.69
|
| Rate for Payer: Ohio Health Group HMO |
$2,790.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,976.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,236.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,566.87
|
| Rate for Payer: PHCS Commercial |
$3,571.30
|
| Rate for Payer: United Healthcare All Payer |
$3,273.69
|
|
|
INSERT IABP PERCUTANEOUS
|
Facility
|
OP
|
$3,720.10
|
|
|
Service Code
|
HCPCS 33967
|
| Hospital Charge Code |
76101324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,116.03 |
| Max. Negotiated Rate |
$3,571.30 |
| Rate for Payer: Aetna Commercial |
$2,864.48
|
| Rate for Payer: Anthem Medicaid |
$1,279.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,901.68
|
| Rate for Payer: Cash Price |
$1,860.05
|
| Rate for Payer: Cigna Commercial |
$3,087.68
|
| Rate for Payer: First Health Commercial |
$3,534.09
|
| Rate for Payer: Humana Commercial |
$3,162.09
|
| Rate for Payer: Humana KY Medicaid |
$1,279.34
|
| Rate for Payer: Kentucky WC Medicaid |
$1,292.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,050.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,745.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,116.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,305.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,273.69
|
| Rate for Payer: Ohio Health Group HMO |
$2,790.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,976.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,236.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,566.87
|
| Rate for Payer: PHCS Commercial |
$3,571.30
|
| Rate for Payer: United Healthcare All Payer |
$3,273.69
|
|
|
INSERT IABP PERCUTANEOUS(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 33967
|
| Hospital Charge Code |
761P1324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$462.26 |
| Rate for Payer: Aetna Commercial |
$462.26
|
| Rate for Payer: Ambetter Exchange |
$241.93
|
| Rate for Payer: Anthem Medicaid |
$198.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$241.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$241.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$290.32
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$420.59
|
| Rate for Payer: Healthspan PPO |
$454.50
|
| Rate for Payer: Humana Medicaid |
$198.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$377.15
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$241.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$241.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$202.17
|
| Rate for Payer: Molina Healthcare Passport |
$198.21
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$314.51
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$200.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$241.93
|
|
|
INSERT IABP PERCUTANEOUS(T
|
Facility
|
IP
|
$3,320.10
|
|
|
Service Code
|
HCPCS 33967
|
| Hospital Charge Code |
761T1324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$996.03 |
| Max. Negotiated Rate |
$3,187.30 |
| Rate for Payer: Aetna Commercial |
$2,556.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,589.68
|
| Rate for Payer: Cash Price |
$1,660.05
|
| Rate for Payer: Cigna Commercial |
$2,755.68
|
| Rate for Payer: First Health Commercial |
$3,154.09
|
| Rate for Payer: Humana Commercial |
$2,822.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,722.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,450.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$996.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,921.69
|
| Rate for Payer: Ohio Health Group HMO |
$2,490.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,656.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,888.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,290.87
|
| Rate for Payer: PHCS Commercial |
$3,187.30
|
| Rate for Payer: United Healthcare All Payer |
$2,921.69
|
|
|
INSERT IABP PERCUTANEOUS(T
|
Facility
|
OP
|
$3,320.10
|
|
|
Service Code
|
HCPCS 33967
|
| Hospital Charge Code |
761T1324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$996.03 |
| Max. Negotiated Rate |
$3,187.30 |
| Rate for Payer: Aetna Commercial |
$2,556.48
|
| Rate for Payer: Anthem Medicaid |
$1,141.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,589.68
|
| Rate for Payer: Cash Price |
$1,660.05
|
| Rate for Payer: Cigna Commercial |
$2,755.68
|
| Rate for Payer: First Health Commercial |
$3,154.09
|
| Rate for Payer: Humana Commercial |
$2,822.09
|
| Rate for Payer: Humana KY Medicaid |
$1,141.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,153.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,722.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,450.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$996.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,164.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,921.69
|
| Rate for Payer: Ohio Health Group HMO |
$2,490.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,656.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,888.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,290.87
|
| Rate for Payer: PHCS Commercial |
$3,187.30
|
| Rate for Payer: United Healthcare All Payer |
$2,921.69
|
|
|
INSERT INDWELLING TUN CATH W C
|
Facility
|
IP
|
$5,810.00
|
|
|
Service Code
|
HCPCS 32550
|
| Hospital Charge Code |
761T1197
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,743.00 |
| Max. Negotiated Rate |
$5,577.60 |
| Rate for Payer: Aetna Commercial |
$4,473.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,531.80
|
| Rate for Payer: Cash Price |
$2,905.00
|
| Rate for Payer: Cigna Commercial |
$4,822.30
|
| Rate for Payer: First Health Commercial |
$5,519.50
|
| Rate for Payer: Humana Commercial |
$4,938.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,764.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,287.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,743.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,112.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,357.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,054.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,008.90
|
| Rate for Payer: PHCS Commercial |
$5,577.60
|
| Rate for Payer: United Healthcare All Payer |
$5,112.80
|
|
|
INSERT INDWELLING TUN CATH W C
|
Facility
|
OP
|
$5,810.00
|
|
|
Service Code
|
HCPCS 32550
|
| Hospital Charge Code |
761T1197
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,998.06 |
| Max. Negotiated Rate |
$5,577.60 |
| Rate for Payer: Aetna Commercial |
$4,473.70
|
| Rate for Payer: Anthem Medicaid |
$1,998.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,260.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,531.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,565.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,402.05
|
| Rate for Payer: Cash Price |
$2,905.00
|
| Rate for Payer: Cash Price |
$2,905.00
|
| Rate for Payer: Cigna Commercial |
$4,822.30
|
| Rate for Payer: First Health Commercial |
$5,519.50
|
| Rate for Payer: Humana Commercial |
$4,938.50
|
| Rate for Payer: Humana KY Medicaid |
$1,998.06
|
| Rate for Payer: Humana Medicare Advantage |
$3,260.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,018.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,764.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,287.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,912.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,038.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,112.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,357.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,054.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,008.90
|
| Rate for Payer: PHCS Commercial |
$5,577.60
|
| Rate for Payer: United Healthcare All Payer |
$5,112.80
|
|
|
INSERT INDWELLING TUN CATH W C
|
Facility
|
OP
|
$6,810.00
|
|
|
Service Code
|
HCPCS 32550
|
| Hospital Charge Code |
76101197
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,341.96 |
| Max. Negotiated Rate |
$6,537.60 |
| Rate for Payer: Aetna Commercial |
$5,243.70
|
| Rate for Payer: Anthem Medicaid |
$2,341.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,260.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,311.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,565.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,402.05
|
| Rate for Payer: Cash Price |
$3,405.00
|
| Rate for Payer: Cash Price |
$3,405.00
|
| Rate for Payer: Cigna Commercial |
$5,652.30
|
| Rate for Payer: First Health Commercial |
$6,469.50
|
| Rate for Payer: Humana Commercial |
$5,788.50
|
| Rate for Payer: Humana KY Medicaid |
$2,341.96
|
| Rate for Payer: Humana Medicare Advantage |
$3,260.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,365.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,584.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,025.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,912.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,388.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,992.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,107.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,448.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,924.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,698.90
|
| Rate for Payer: PHCS Commercial |
$6,537.60
|
| Rate for Payer: United Healthcare All Payer |
$5,992.80
|
|
|
INSERT INDWELLING TUN CATH W C
|
Professional
|
Both
|
$6,810.00
|
|
|
Service Code
|
HCPCS 32550
|
| Hospital Charge Code |
76101197
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$158.77 |
| Max. Negotiated Rate |
$4,086.00 |
| Rate for Payer: Aetna Commercial |
$387.12
|
| Rate for Payer: Ambetter Exchange |
$190.73
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$158.77
|
| Rate for Payer: Anthem Medicaid |
$580.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$190.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$190.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$228.88
|
| Rate for Payer: Cash Price |
$3,405.00
|
| Rate for Payer: Cash Price |
$3,405.00
|
| Rate for Payer: Cigna Commercial |
$356.09
|
| Rate for Payer: Healthspan PPO |
$956.72
|
| Rate for Payer: Humana Medicaid |
$580.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$307.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$190.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$591.96
|
| Rate for Payer: Molina Healthcare Passport |
$580.35
|
| Rate for Payer: Multiplan PHCS |
$4,086.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$247.95
|
| Rate for Payer: UHCCP Medicaid |
$166.71
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$586.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$190.73
|
|
